Injury is the leading cause of death of children in the United States.
Orotracheal intubation is the most reliable means of securing an airway.
Hypovolemic shock is caused by blood loss, which makes up 8% to 9% of the body weight of a child. Determining the extent of volume depletion and shock requires evaluation of multiple parameters.
Attempt vascular access en route.
Intraosseous (IO) access should be obtained for immediate fluid resuscitation if attempts at intravenous (IV) cannulation are unsuccessful after 3 attempts or within 90 seconds.
For shock, give a rapid initial infusion of 20 mL/kg of crystalloid solution.
Unique characteristics of the pediatric cervical spine (C-spine) predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury.
Radiographs to be obtained as soon as possible in the setting of major blunt trauma include lateral cervical spine, antero-posterior (AP) chest, and AP pelvis views.
Injury is the leading cause of deaths in children in the United States, representing almost 40% of all pediatric fatalities.1 Approximately 20,000 children die as a result of injury per year. For every child that dies from an injury, 40 others are hospitalized and 1120 are treated in EDs.2 Up to 70% of pediatric patients die prior to arrival at a center capable of providing care.3
Mortality data alone does not reveal the profound impact of trauma. For children less than 19 years of age, injuries are the leading cause of visits to EDs, numbering 9 million, accounting for more than 225,000 admissions, and resulting in nearly $87 billion in health care and societal costs.1 Even minor injuries can have lasting effects, causing physical or cognitive functional impairment and affecting quality of life years after the acute traumatic event. Therefore, the physical, emotional, and psychological needs of the child and family must be considered.
Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate following major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey.4 Pain evaluation and control as well as constant reassessment ensures quality of care.
Blunt trauma is the predominant mechanism of injury in children, with only 10% to 20% suffering penetrating injury.2 Boys are injured twice as frequently as girls. Motor vehicle crashes (MVCs) account for more than half of all childhood trauma deaths.1 Other major causes of death are falls, drowning, poisoning, and fire-related injuries, with the relative incidence for each injury type varying by age group (Table 23-1).5
| <1 y | 1–4 y | 5–9 y | 10–14 y | 15–24 y |
|---|---|---|---|---|
| Congenital Anomalies | Unintentional Injury | Unintentional Injury | Unintentional Injury | Unintentional Injury |
| Prematurity | Congenital Anomalies | Malignant Neoplasms | Malignant Neoplasms | Suicide |
| Sudden infant death syndrome | Homicide | Congenital Anomalies | Suicide | Homicide |
| Maternal Pregnancy Complications | Malignant Neoplasms | Homicide | Homicide | Malignant Neoplasms |
Children have anatomic, physiologic, and psychological responses to trauma that are different from those seen in adults, and an understanding of these differences is essential to provide appropriate care for children. Kinetic energy from injury is distributed over a smaller area and impacts a greater proportion of the total body volume. Musculoskeletal compliance is greater in children, and they have less protective muscle and subcutaneous tissue. The increased flexibility and resilience of the pediatric skeleton and surrounding tissues permits external forces to be transmitted more readily to the deeper internal structures. Always consider the possibility of internal injury, even in the absence of external signs of trauma.
A child’s head represents a larger percentage of total body mass than that of an adult, and head injuries are very common in children. The head is also a major source of heat loss in a child. The occiput is more prominent in young children and decreases in prominence from birth until approximately 10 years of age; this factor must be taken into account when positioning the head for intubation and airway management (Fig. 23-1). The bony sutures are open at birth, gradually fuse and completely close by 18 to 24 months of age. At times, accessory sutures can be misinterpreted as fractures. Recognize that parietal and occipital bones are common regions for accessory sutures due to their multiple ossification centers. Radiographic evidence of sutures show a zigzag pattern with interdigitations and sclerotic borders versus sharp lucencies with non-sclerotic edges when related to a non-depressed skull fracture. Also, fractures and accessory sutures can be differentiated by characteristics such as bilaterality, symmetry, associated diastasis, and presence of soft tissue swelling.6 A bulging fontanel in younger infants in the setting of trauma suggests increased intracranial pressure (ICP) from hemorrhage or edema.7
A younger child’s neck is shorter and supports a relatively heavier weight than an adult’s, making it especially vulnerable to forces of trauma and sudden movements. A younger child’s short, thicker neck makes it difficult to evaluate neck veins and tracheal position, challenging the physician’s ability to rule out tension pneumothorax and SVC obstruction. Also, unique features of the pediatric spine (higher fulcrum of movement due to having a larger head size, incompletely ossified vertebrae, stronger ligamentous attachments than bone and more horizontal articular surfaces) lead to higher risk of ligamentous and spinal cord injuries, especially in younger children. Due to these differences, spine injuries in children, while overall low in incidence, when present occur most commonly in the cervical spine (60%–80% of all spine injuries).8
The most dramatic and critical differences between children and adults are in the airway. A child’s larynx is located in a more cephalad and anterior position. In addition, the epiglottis is tilted almost 45 degrees in a child and is floppier, making manipulation and visualization for intubation more difficult. Unlike the adult, where the glottis is the narrowest portion of the upper airway, the cricoid cartilage just inferior to the larynx is the narrowest portion of the child’s airway. As mentioned above, due to a child’s larger head and prominent occiput relative to body size, the neck flexes in the supine position leading to airway obstruction. A folded towel as a shoulder roll is recommended to achieve a neutral position of the neck and open the airway (Fig. 23-1). All these differences are most pronounced in neonates and infants under 1 year of age; after age 2 these changes become less prominent, typically maturing to adult physiology by age 8.9
The pediatric thorax is more pliable because of flexible ribs and cartilage, with less overlying fat and muscle. This allows a greater amount of blunt force to be transmitted to underlying tissues. The diaphragmatic muscle is much more distensible in a child. A child’s mediastinum is also very mobile. Therefore, the thoracic and abdominal organs are subject to sudden, wide excursions that can be life-threatening, as in tension pneumothorax.
The diaphragm inserts at a nearly horizontal angle from birth until approximately 12 years of age, in contrast to the oblique insertion in the adult. This pushes the abdominal organs inferiorly relative to adult positioning, causing these organs to be more exposed and less protected by ribs and muscle. Therefore, seemingly insignificant forces can cause serious internal injury.
The spleen and the liver are in a more caudal and anterior position. Even though the increased elasticity and compliance of a child’s connective tissue and suspensory ligaments should protect these organs, they are actually more subject to injury because of the increased motion at impact.
Long bones in children differ from the adult because of the presence of growth plates and increased compliance (Chapter 30). Ligaments are stronger than the growth plate, predisposing a child to physeal fractures, as categorized by the Salter-Harris classification system (Fig. 30-2).10
A higher surface-to-mass ratio predisposes children to temperature instability, particularly hypothermia (discussed in the Exposure section below).
The differences in mechanisms and patterns of injury observed in early childhood, late childhood, and adolescence, together with immature anatomic features and the developing physiologic functions of the pediatric patient, result in unique responses to major trauma, which in turn drive the need for specialized pediatric resources. The injured pediatric patient has special needs that may be provided optimally at a children’s hospital with demonstrated expertise in and commitment to both pediatric and trauma care, which can decrease injury-related mortality.11 Geographic areas with access to a pediatric trauma center should integrate them into the regional trauma system through invited participation, appropriate field triage, and interfacility transport of the most critically injured children.12 When a pediatric trauma center, whether freestanding or affiliated with an adult trauma center, is not available, this role should be fulfilled by the adult trauma center with the largest volume of pediatric patients.3,13–15
Considerations in the field care of the traumatized child include airway management, IV access, immobilization, and rapid transport. Which procedures should be attempted in the prehospital setting is controversial, but rural systems may require more aggressive initial treatment than those in urban areas because of longer transport times.16 The prehospital success rate for endotracheal intubation varies based on injury severity, age of the patient, education level of the health care provider, and use of neuromuscular blockade to facilitate intubation.17 Temporizing airway interventions such as bag-mask ventilation or laryngeal mask airway placement may be helpful until a definitive airway is placed, to avoid delay in transport.18
Vascular access is a difficult procedure under the best of circumstances and is often a reason for delay in transport of a critically ill child. It is reasonable for traumatized children to be transported immediately without vascular access if a short transport time is expected. Vascular access can be attempted en route to avoid prolonged scene time. Intraosseous (IO) infusion (Fig. 23-2) should be used as a quick access route if attempts at IV cannulation are unsuccessful after three attempts or within 90 seconds.19 IO lines can be placed rapidly and successfully in the prehospital setting.20
The highest priority is immediately identifying and treating life-threatening injuries (Fig. 23-3). The next priority is identifying injuries requiring operative intervention. Finally, the child is examined for non-life-threatening injuries, and definitive management is initiated (Table 23-2). There are recognized criteria for transferring a patient to a trauma center or activating an in-house trauma team (Tables 23-3 and 23-4). It has been demonstrated that the presence of a trauma resuscitation team can decrease mortality by 25% to 30% for the seriously injured child.21
|
Trauma team to the ED Penetrating wound (head/neck/torso) Tachycardia/poor perfusion Blood prior to arrival SBP <90 (age appropriate) 40 mL/kg bolus prior to arrival Respiratory distress/failure GCS ≤8 GCS deterioration by 2 Trauma alert Ejected from motor vehicle Extrication time >20 min Fatality of another passenger in MVC Intrusion of vehicle >20 in by collision Vehicle traveling >20 mph in pedestrian accident or passenger unrestrained in MVC (>35 mph restrained) Fall >20 ft Run over by vehicle Lightning Major electrical injury Significant injuries both above and below the diaphragm Two or more proximal long bone fractures Burn of >15% BSA Traumatic amputation of limb proximal to wrist or ankle Crush injury of torso Spinal injury with paralysis |
|
Have available weight-based equipment tables or height-based reference tools (such as the Broselow tape [Fig. 23-4] as an aid in determining equipment sizes and medication dosing).
Conduct the primary survey and initial resuscitation simultaneously, usually during the first 5 to 10 minutes, and focus on diagnosing and treating life-threatening disorders.22 Continue the secondary survey with a more thorough physical examination and diagnostic testing. This is an anatomic survey that evaluates in a timely, directed fashion each body area from head to toe. In this fashion, life-threatening injuries are promptly recognized before proceeding to less urgent problems. Children with serious injuries require continual reassessment. Perform repeat vital signs every 5 minutes during the primary survey, and at least every 15 minutes during the secondary survey and while awaiting transfer or operative intervention.4
The primary survey includes evaluation of the airway, adequacy of breathing, ventilation effort and assessment of neurologic disability, along with stabilization of the cervical spine (C-spine).4,23 Next, evaluate the circulatory status and control hemorrhage, then evaluate for disability (neurologic screening examination). This is followed by exposure (clothing removal) and brief but thorough general examination. Remember to avoid hypothermia by keeping the child warm, and maintain patient modesty as much as possible. Conduct the primary survey and resuscitation simultaneously. Vital signs vary by age, and one should have access to a table or chart with them (Table 23-5).
| Age | Weighta (kg) | Respiratory Rate | Heart Rate | Systolic BPb |
|---|---|---|---|---|
| Preterm | 2 | 55–65 | 120–180 | 40–60 |
| Term newborn | 3 | 40–60 | 90–170 | 52–92 |
| 1 mo | 4 | 30–50 | 110–180 | 60–104 |
| 6 mo–1 y | 8–10 | 25–35 | 120–140 | 65–125 |
| 2–4 y | 12–16 | 20–30 | 100–110 | 80–95 |
| 5–8 y | 18–26 | 4–20 | 90–100 | 85–100 |
| 8–12 y | 26–50 | 12–20 | 60–110 | 90–115 |
| >12 y | >40 | 12–16 | 60–100 | 100–130 |
The airway is secured while concomitantly stabilizing the neck. Use the jaw thrust maneuver to open the airway and clear the oropharynx of debris and secretions. Although children sustain bony C-spine injuries less frequently than adults, they are at high risk for cervical cord injuries. Approximately 30–40% of children with traumatic myelopathy have a spinal cord injury without radiological abnormality (SCIWORA).4 C-spine injury should be assumed and C-spine immobilization maintained until definitive clearance can be performed.
Indications for endotracheal intubation in the trauma patient include the inability to ventilate the child by bag-valve-mask methods, the need for prolonged control of the airway, prevention of aspiration in a comatose child, or the need for controlled mild hyperventilation in patients with serious head injuries. Also consider it for flail chest with pulmonary contusion, in patients with shock that is unresponsive to fluid volume, and in those with Glasgow Coma Scale (GCS) 8 or less.24
Orotracheal intubation is the most reliable means of securing an airway. Appropriate tube size is approximated by age (formula: (age/4) +4, subtract 0.5 for cuffed tube) (Table 23-6); through the use of a height-based reference tool such as the Broselow tape (Armstrong Medical, Lincolnshire, IL) (Fig. 23-4); or can be estimated using the diameter of the nostril or the diameter of the child’s fifth finger. Other useful approximations include the following:
| Age | Mask Size | Oral Airway | Nasal Airway | Laryngoscope Blade | Endotracheal Tube (mm) | Foley Catheter | Orogastric Tube (F) | Suction Catheter | Chest Tube | Vascular Catheter | IO Needle (G) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Newborn | Infant | 0 | 0 | 3–3.5 | 5–8 | 5 or 8 feeding | 8 | 12–18 | 20–22 | ||
| 6 mo | Infant/child | 1 | 12 | 1 | 3.5 | 8 | 8 | 8 | 14–20 | 20–22 | 17 |
| 1 y | Child (s) | 1–2 | 12 | 1 | 4.0 | 8 | 10 | 8 | 14–24 | 20–22 | 17 |
| 3 y | Child (s) | 2 | 16 | 2 | 4.5 | 10 | 10 | 10 | 16–28 | 18–22 | 15 |
| 5 y | Child (m) | 3 | 16 | 2 | 5.0 | 10 | 10–12 | 10 | 20–32 | 18–20 | 15 |
| 6 y | Child (m) | 3 | 16 | 2–3 | 5.5 | 10–12 | 12 | 10 | 20–32 | 18–20 | |
| 8y | Sm med | 4 | 20 | 2–3 | 6.0 | 12 | 14 | 12 | 24–32 | 16–20 | |
| 12 y | Med lg | 4–5 | 24–28 | 3 | 6.5 | 12–16 | 14 | 12 | 28–36 | 16–20 | |
| 16 y | Med lg | 5 | 28–30 | 3–4 | 7.0–8.0 | 14–18 | 16–18 | 12–14 | 28–40 | 14–18 |
2 × ETT = NG/OG/Foley catheter size
3 × ETT = depth of ETT insertion
4 × ETT = chest tube size (maximum, e.g. hemothorax)25
Nasotracheal intubation should not be performed if there is any concern for facial trauma, and should otherwise only be considered as an alternative to orotracheal intubation or with fiberoptic-assisted devices.26 Besides being extremely difficult in an acutely injured child, it is relatively contraindicated because of the acute angle of the posterior pharynx, the necessity of additional tube manipulation, and the probability of causing or increasing pharyngeal bleeding. Preparation should always precede intubation and includes guaranteeing the presence of all equipment and drugs necessary to adequately manage an acute airway, including a range of ETT and laryngoscope blade sizes. This should be accomplished even before an injured child arrives.
Intubation may be necessary to maintain an adequate airway. However, intubation may be difficult because of poor airway visualization, seizures, agitation, or combativeness. Prolonged intubation procedures can lead to ICP elevation, pain, bradycardia, regurgitation, and hypoxemia. Rapid sequence induction (RSI) can greatly facilitate intubation and reduce adverse effects significantly (Chapter 18).
Emergency physicians must be able to secure an airway when unable to perform orotracheal or nasotracheal intubation. There are several options:
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
